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B-19-903 - 0029 BOSTON STREET - Building Permit z The Commonwealth of Massachusetts CITY OF r ' .. �c Board of Building Regulations and Standards I-: i�i �n� SALE M Massachusetts State Building Code,780 CMR (�, ,J -- Revised'Mar 2011 l� 1 Building Permit Application To Construct,Repair,RencR*.bib) IiA a,1D 2-7 One-or Two Family Dwelling This Section For:Oflicial Llse Opl ' Buil4ij Permit Ntimber Date Applied e. r,; r c s .4 d>yig OfEctaa am e Signature Dat6 r(� `BECTIO, f. S' Hula oRMATI JIB I 1.1 Prop �dr rty Aesss. 1.2 Assessors Map&Parcel Numbers -2� � - - z ` :- t s'i c 1 l.la Is this an accepted street?yes , 'l no ;; , ' Map Number t p -Parcel Number 1.3 Zoning Information: , 1.4 Property Dimensions: (J1 �} C. 'Y.;�v �'3.Ja,�a '•42....1:r�a.dt_:. i.. lit +i..f .'Sn fY` Zoning District Proposed Use Lot Area(sq R) Frontage(R) ,fit ... 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Requred Provided Required Provided Required Provided 1.6 Waiter Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: �� 1.8 Sewage Disposal System: Zone: Outside Flood Zone?` Public C1 Private❑ — Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2z. PROkERTY OERSII)<IIPI. 2..11 O er'of Record: Z,4 0Z C 40V J4_„ I" 1V�r ri•a���T���-- � Name(Print)' City,State,ZIP No.and'Street Telephone Email Address SECTION 3 DESCRIPTION`OF PROPOSED WORIC�Nheck all that apply) New Construction❑ Existing Building* Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Propgsed Work2• SIC— Allf WAN \ SECTION 4:EST14ATED CONSTRUCTION COSTS Estimated Costs: Item Offieral.Use Qnly Labor and Materials 1.Building $ i ButldLag Permit Fee:$ Indt�ate how fee is determined: 2.Electrical $ ❑Standard City/1 own Application Fee C]Total Project Cost(Item 6)x mul#plier x 3.Plumbing $ 2 Other Fees $ 1 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Total Ail Fees;$ Suppression) Check No Cheek Amount Cash Amount 6.Total Project Cost: $ /2 (�O'(� ❑Paid in Fuld Outstandin Balance.Due g - - I SECTION 5 CONSTRUCTIONEtVICES 5.1 Construction Supervisor License(CSL) r C'.s���'�Z6 L � 2 2 -?.;o i License Number Expiration Date Name of CSL Holder V �' 1J List CSL Type(see below) Ca C- I o.and Street TYI Descsiphon 4A��� 14 A- 02037 U Unrestricted(Buildings u to 35,000 cu.ft. (� R Restricted 1&2 FamilyDwelling City/town,State,ZIP M Masonry i RC Ro.ofing Coveringt WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D I Demolition . 5.2 Registered Home Improvement Contractor(HIC) MMJ r '\ HIC Registration Number Expiration Date HIC Comp Name or HIC Registrant Name No.and S4eet !w4 � Email address 2�� Ci /Town State,ZIP Telephone SECTION 6 WO1EtKERS'COMPENSATION E SURANCE AFFIDAVIT(M G;L.c 152 §25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........A No .❑ SECTION 7a.is OWNER AUTHbRIA 1GU TO B COIYIPLETED WHEN QWNER'$A G IT QJR CQNTRACTOR AI'PhIES FOR BUI ,1)IiVG PER]YI1T ' I;:as Ownerlof the subject property,hereby.authorize �: •, 1 r Ito act on my behalf,in all matters relative to work authorized by this building permit applicatton. " Print Owner's Name(Electronic Signature) Date SECTION 76:OWNER.O)( AUTIFIORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Ez�g�z- Ld Zib" Print Owner s or Authorized Agent's Name Xlectronic Signature) yv Date NQT)ES :. 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mmL. og v/oca Information on the Construction Supervisor License can be found at www.mass.7ov€ /das 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' • e M f CITY OF S.,UEINI, N ksSACHusETTS • BUUM04G DEPART.%ILNT 4 `1 120 WASHINGTON STREET, r FLOOR 'O TEL (978) 745-9595 FAX(978)740-9846 Kjmum RY DIUSCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUII.DING CONaUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicatnt Information Please Print Leeibly 1 Name(tlusimissiOrganization/Individual): MOV) EJAL �c. Qari `�p 4. WO-44(t�,t 2—A.U\ 1� Address: 20 Ca ct.. I)[ City/Suite/Zip: rUJACAt_ IKA- �?�?� Phone #:_ Tt�t — Yam— f 2&{� Are you can employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with _'5--_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have li. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its 10❑ Electrical repairs or additions required.) officers have exercised their 3.❑ [am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions mysgif.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.❑Other, comp. insurance required.] •Any applirtrpl that checks box tl t must also fill out the section below showing their workers'compensation policy information. l fimwownc p who submit this affidavit indicating they ate doing all work and them hire otnsido eontraetont must submit a new affidavit indicating such. =Contmtors that cheek this box must attached an additional sleet showing the name of the sub-cone wen and their workm'comp.policy information. I ant an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and Job site informutioer. Insurance Company Name:_ lei 1jr_—o . 4i10-1 4( Policy#or Self-ins.Lie.#:wt..S /'Z OOO Expiration Date:_ 5: Job Site Address: 7,7 664jm, �-`-� City/State/Zip:_ Iew%% ' ~- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S2 i0.00 a day against the violator. Be advised that a copy of this s f may be forwarded to the Office of tnvt tigrtit)ns of the DIA for insurance c age verification. I do hereb)P certify turder t aerd penaltie perjury that the information provided above is true and correct. . i lni tar ' Date: Zo- Po #• t7 - 12 Ofcial us only. Do not write in this area,to be completed by city or town officiaL City or"Town: Permit/I.icense Issuing Authority(circle one): 1. Boar(]of health 2.Building Department 3.City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6.Othetr Contact Person: Phone#• i CITY OF SALEM, MASSAMUSE M ` BIN MG DEPARnXNr 12.0 WASHNGTONSTREET,3 RD F1WR TEL(978)745-9595 BIMBERLEYDRISQOLL FAX(978)740-9846 MAYOR THOUM STAERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING 001,WSSIOMR Construction Debris Disposal Affidavit (required for all demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40,S54; Building Permit# condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111, S150A. The debris will be transported by: (name of hauler) The debriswill be disposed of in: wit).Ac-�Wk- TCVj b 014-. (narne of facility) ` U 4� S (addiress of facility) Sig u of icant ., 2.0 today's date) .f2S C�o�rr.Sao.�ei„eo,�',�pa�✓�d.J<1ac�ar�J :;: I Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR T1r Corporation i�eg7sM �-05/11/2020 NEW ENGLAPIpI CCO& ' WEATHERIZA STEVEMWOLP 158 ASH ST HOPKINTON, I Undersecremq € imp Commonwealth of Massachusetts Division of Professional Licerisure Board of wilding Regulations and Standards ConstrCtt�r�fS�iSpervisor CS-097262WT : •, cpires: 09/22/2020 STEVEN WOL-PE PO BOX 112 HANOVER MA 338`` L� xy}yw'!`�1gS T30�S COMMission.er k Salesman:! NEW ENGLAND BRICKFACE -- Date: Z 5 • 4Weatherization , Registration# 178685 158 Ash Street- Hopkinton, MA 01748 Tel: 508-435-8705 Fax: 508-435-6556 F.I.D.#26-4530588 Notice:All home improvement contractors and subcontractors engaged in home improvement contracting in Massachusetts,unless specifically exempt from registration by provisions of Chapter 142A of the General Laws,must be registered with the commonwealth of Massachusetts.Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108 THIS AGREEMENT,between NEW ENGLAND BRICKFACE STUCCO&WEATHERIZATION,INC.OF HOPKINTON,MA herein referred to as"Contractor"and CUSTOMER NAME herein referred to as"customer" c ` , ADDRESS ;694 CITY ��`.�h STATE �¢ ZIP .i o . CUSTOMER TEL.# JOB ADDRESS 2 I � WITNESSETH in consideration of the undertakings herein expressed,Contractor and Customer do hereby agree as follows, YES NO JOB SPECIFICATIONS ERECT SCAFFOLDING WHERE CONTRACTOR DEEMS NECESSARY x APPLY VAPOR BARRIER WHERE CONTRACTOR DEEMS NECESSARY. APPLY 3.4 DIAMOND MESHGALVANUZED STEEL LATH TO SPECIFIED WORK AREAS APPLY FORMULA SCRATCH COAT OF CEMENT TO SPECIFIED WORK AREAS k V- APPLY NEW ENGLAND BRICKFACE STUCCO&WEATHERIZATION FINISH �- ` ties ELEVATIONS WORK AREAS DESCRIPTIONS le-o C^ a,c_ bL • _..._._ _...-- DETAIti CHECKLIST YES NO AREA YES NO AREA FOUNDATION .Vf FLASHING OR COUNTERFLASHING FASCIA X STAIR RISERS CHIMNEY STAIR CHEEKS X SOFFIT COLUMNS YES NO DOOR,WINDOW SILLS OR FRAMES \ REMOVE SHUTTERS REINSTALL? -Joe. EXPANSION JOINTS IF AND WHERE CONTRACTOR DEEMS NECESSARY REMOVE SIGNS REINSTALL? ,4 CASING ESEADS IF AND WHERE CONTRACTOR DEEMS NECESSARY I REMOVE LEADERS REINSTALL? SPECIFICATION FINISH OR COLS ..I r MORTAR I TOWING TEXTURE # NAME I # NAME I # NAME i � L 4 Cam - v flAA CONTRACT PRICE INCLUDING ALL APPICABLE DISCOUNTS AND TAXES................... $ &OCR ar0 *�*PAVMFNTC!`TJFTITIT l�*** 1 x APPLY VAPOR BARRIER WHERE CONTRACTOR DEEMS NECESSARY APPLY 3-4 DIAMOND MESHGALVANUZED STEEL LATH TO SPECIFIED WORK AREAS APPLY FORMULA SCRATCH COAT OF CEMENT TO SPECIFIED WORK AREAS Y i APPLY NEW ENGLAND BRICKFACE STUCCO&WEATHERIZATION FINISH o_ ` ELEVATIONS WORK AREAS DESCRIPTIONS tD DETAIL CHECKLIST YES NO AREA YES NO AREA FOUNDATION FLASHING OR COUNTERFLASHING FASCIA X STAIR RISERS x CHIMNEY STAIR CHEEKS X SOFFIT COLUMNS y YES NO DOOR,WINDOW SILLS OR FRAMES REMOVE SHUTTERS REINSTALL? EXPANSION JOINTS IF AND WHERE CONTRACTOR DEEMS NECESSARY REMOVE SIGNS REINSTALL? yC. CASING BEADS IF AND WHERE CONTRACTOR DEEMS NECESSARY REMOVE LEADERS REINSTALL? SPECIFICATION FINISH COLORS MORTAR TOWING TEXTURE # NAME # NAME NAME G 4A^ . CONTRACT P11ICE INCLUDING ALL APPICABLE DISCOUNTS AND TAXES................... $ ***PAYMENT SCHEDULE*** DEPOSIT PAID(25%).................. AFTER LATH(?5%).................................................................................................... $ 2 AFTERBASE COAT(25%)........................................................................................... $ r U ON COMPLETION(before removal of scaffold)(25%)........................................................... $ ' ?� _ NOTICE TO CUSTOMER THE TERMS OF THIS CONTRACT ARE CONTAINED ON BOTH SIDES OF THIS PAGE. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. YOU ARE ENTTLED TO A COPY OF THIS CONTRACT AT THE TIME YOU SIGN IT. KEEP IT TO PROTECT YOUR LEGAL RIGHTS. WE, THE AFORESAID CUSTOMERS CERTIFY THAT IMMEDIATELY AFTER THE SIGNING OF THE AFORESAID AGREEMENT, A COMPLETELY•EXECUTED COPY WAS FURNISHED TO US. YOU, THE BUYER MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIR BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR LA TION OF THIS RIGHT, WITNESS �^ ! L.S. sto er) (Date) APPROVED_ L.S. (Customer) (Date) k NEWENGL-43 _ MWOLF •:.ACORO' - DATE(MMMDIYY" CERTIFICATE OF LIABILITY INSURANCE 4/30/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIvI,?OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the pol(cy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s)- PRODUCER License#,1780862 ME CT HUB International Now England NCO,NNE%r :(978)657-5100 (AIC,No:978 988-0038 300 Ballardvale Street ( ) Wilmington,MA 01887 1D SS. INSURERS AFFORDING COVERAGE. NAIC# INSURER A:Main Street America Assurance Company 29939 INSURED INSURER a:National Grange Mutual Insurance Company 14788 New England Brickface,Stucco&Weatherization;Inc. INSURER C c/o Lawrence Cargill 20 Canjill Street INSURER 0: Melrose,MA 02176 INSURER E: I - INSURER F: r COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY,BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE IAWL NSD SUER POLICY NUMBER POLICY EFF POLICY EXP WVD LIMITS A X COMMERCIAL'GENERAL LIABILITY EACH OCCURRENCE $ 1,000+000 ' CLAM54*DE �X OCCUR X X MPS12289 5/5/2019 5/5/2O2o. DAMAGE TO RENTED n $ 500,000 MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 NEN'L AGGREGATE:LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,600 POLICY❑X JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: B AUTOMOBILE u4ii rrY C eM SINGLE LIMIT $ 1,000,000 aBIM e2n ANY AUTO X M3S12000 5/5/2019 5/5/2020 BODILY INJURY Per person $ OWNED SCHEDULED AUTEEO��S ONLY X AUUT�}OpSWNE � BODILY INJURY(Per accident $ Ix AIITRTOS ONLY X AUTOS ONLY PPR�OBERd t AMAGE $ $ B X UMBRELLA UAS X OCCUR EACH OCCURRENCE - $ 2,000,000 EXCESS LIASt CLAMS-MADE CUS12000 9/24/2018 9/24/2019 AGGREGATE '$ 2,000,000 DED I X I RETENTION$ 10,000. B WORKERS COMPENSATION PER 'X OTH- AND EMPLOYERS'LIABILITY YIN TAER ANY PROPRIETOR/PARTNERIF�CUI IVE WC312000 - 5/5/2019 5/5/2020 1,000,000 �FFICERIMF,Mg��EXCLUDED? ❑N N/A E.L.EACH ACCIDENT $ (Mandatory m NH) 1,000,000 E.L.DISEASE-EA EMPLOYE If yes describe under 1,000,000 DESCRIPTION F OPERATIONS below E.L.DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE proof of coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD